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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 071440415
Report Date: 03/22/2022
Date Signed: 03/22/2022 03:29:07 PM

Document Has Been Signed on 03/22/2022 03:29 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:VILLA BOARD AND CARE HOMEFACILITY NUMBER:
071440415
ADMINISTRATOR:VILLA, DANIEL D.FACILITY TYPE:
740
ADDRESS:831 CORAL DR.TELEPHONE:
(510) 799-5572
CITY:RODEOSTATE: CAZIP CODE:
94572
CAPACITY: 6CENSUS: 1DATE:
03/22/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Daniel Villa, AdministratorTIME COMPLETED:
03:40 PM
NARRATIVE
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On 03/22/2022 at 1:20 pm, Licensing Program Analysts (LPAs) C. Fowler and L. Hall arrived unannounced to conduct a POC visit. LPAs met with Administrator, Daniel Villa and explained the purpose of the visit.

Upon arrival LPAs had not received any POCs from Administrator.

Administrator requested for extension on 3/11/2022 submission of POC for deficiencies cited from annual inspection date 3/03/2022. The POC due dates were 3/11/2022 with the exception of section #87705(f)(1) with the due date of 3/5/2022. The proof of corrections for deficiencies section #87705(f)(1) and 87211(a)(1) were cleared during POC visit. Administrator requested extension due to a fall. LPA C. Fowler extended the request until 3/15/2022 with the exception of sections 87621(b)(1)(B) and 87606(f)(1).

On this same day, LPA C. Fowler discussed with Administrator the above and informed him that LPA C. Fowler will recite. An immediate Civil penalty of $500 was issued today.

Deficiency section 87606(f)(1) is re-cited--refer to LIC809D. Failure to submit proof of correction by plan of correction due date may result in civil penalty.

Plan and proof of correction was discussed with Administrator.

Exit interview conducted. Appeal Rights and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 03/22/2022 03:29 PM - It Cannot Be Edited


Created By: Carol Fowler On 03/22/2022 at 02:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: VILLA BOARD AND CARE HOME
FACILITY NUMBER: 071440415

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/23/2022
Section Cited
CCR
87606(f)(1)

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87606(f)(1) (f) To accept or retain a bedridden person, a facility shall ensure the following: (1) The facility's Plan of Operation includes a statement of how the facility intends to meet the overall health, safety and care needs of bedridden persons. This requirement was not met as evidence by:
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Administrator agreed to apply for a fire clearance and update the facilities Plan of Operation and provide a copy to CCLD by the POC date.
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Based on LPAs observation licensee did not comply with the section cited above by accepting a bedridden resident with restricted health condition without fire clearance in room #1. Which poses an immediate health and safety risk to clients.
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Type A
03/23/2022
Section Cited
CCR87621(b)(1)(B)

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87621(b) In addition to Section 87611 the licensees shall be responsible... (1) Ensuring that ostomy care is provided by an appropriately...(B)There shall be written documentation by an appropriately skilled professional outlining...instruction...facility staff who have been instructed. This requirement was not met as evidence by:
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Administrator agreed to apply for a fire clearance and update the facilities Plan of Operation and provide a copy to CCLD by the POC date.
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Based on LPAs observation licensee did not comply with the section cited above by accepting a bedridden resident with restricted health condition without fire clearance in room #1. Which poses an immediate health and safety risk to clients.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2022


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/22/2022 03:29 PM - It Cannot Be Edited


Created By: Carol Fowler On 03/22/2022 at 02:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: VILLA BOARD AND CARE HOME
FACILITY NUMBER: 071440415

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/29/2022
Section Cited
CCR
87506(b)(17)(A)(B)

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87506(b) Each resident’s record shall contain at least the following ...(17)Documents and information required...(A)Section 87457, Pre-Admission Appraisal;(B)Section 87459, Functional Capabilities;(C) Section 87461, Mental Condition; (D)Section 87462, Social Factors This requirement was not met as evidence by:
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Administrator agreed to provide a copy of the Mitigation Plan to CCLD by POC date.
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Based on LPAs observation licensee did not comply with the section cited above by missing required documentation in residents files, Pre-placement Appraisal Needs and Services Plan, Identification and Emergency Information, Consent for Medical Treatment and Residents Rights. Which poses a potential health and safety risk to residents.
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Type B
03/29/2022
Section Cited
CCR87303(a)

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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by:
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Administrator agreed not to allow staff to sleep in the garage. Facility will submit a written addendum to their operating plan describing how the garage will be utilized as intended to CCLD by POC date.
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Based on LPAs observation licensee did not comply with the section cited above by not providing a grab bar in the bathtub. having a hole in the ceiling from an upstairs bathroom leak in the shared bathroom. Using a screwdriver to operate the shower faucet in bedroom #1. Which poses a potential health and safety risk to residents.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/22/2022 03:29 PM - It Cannot Be Edited


Created By: Carol Fowler On 03/22/2022 at 02:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: VILLA BOARD AND CARE HOME
FACILITY NUMBER: 071440415

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/29/2022
Section Cited
CCR
87208(A)(7)

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87208((A) Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended...7)Sketches, showing dimensions, of the following: This requirement was not met as evidence by:
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Administrator agreed not to allow staff to sleep in the garage. Facility will submit a written addendum to their operating plan describing how the garage will be utilized as intended to CCLD by POC date.
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Based on LPAs observation licensee did not comply with the section cited above by staff sleeping in the garage in a makeshift bedroom being used for accommodation. Which poses a potential health and safety risk to residents.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2022


LIC809 (FAS) - (06/04)
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